ORIGINAL ARTICLE
MENTAL HEALTH CARE IN JAPAN: BALANCING CARE IN HOSPITALS AND IN
THE COMMUNITY
*Sayo Hattori1, Atsuro Tsutsumi2, Munehito Machida1 and Graham Thornicroft3
1 Department of Global Health, Graduate School of Medicine, Kanazawa University, 13-1 Takara-machi, Kanazawa-city,
Ishikawa, 9208640, Japan
2 Organization of Global Affairs, Kanazawa University, Kakuma-machi, Kanazawa-city, Ishikawa, 9201192, Japan
3 Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De
Crespigny Park, London SE5 8AF, United Kingdom
*Corresponding author: Sayo Hattori Email: shjpmh@outlook.com
ABSTRACT
In Japan, the number of people with mental illness, especially depression and dementia, is growing. Although mental health care in Japan is in its transition phase from traditional hospital-based care to community-based in the recent decades, it has been characterized by orientation to large psychiatric institutions. This paper aims to provide recommendations for achieving well-balanced mental health care both in hospital and the community in Japan by reviewing facilitators and barriers of current mental health care system. A narrative literature review was conducted to identify facilitators and barriers to implementing community-based mental health care in Japan. The databases PsycInfo, Medline, Pubmed, CiNii and Google Scholar were searched in English and Japanese. 46 studies published from 1980 to 2016 were included in the review. The review identified six categories of mental health care services provided in the Japanese community: Outpatient clinics, Outreach services, Rehabilitation and Living support, Case management and public health centers, Community-based residential care, and Work and Occupation. The crosscutting themes of facilitators and barriers to implement these services in the community were funding, staff management, and collaboration among community resources. To further promote the transition to community mental health care in Japan, this paper recommends the following actions: to shift funding and human resources from inpatient to community care services, to strengthen a capacity building system and supportive environment for service providers in the community, and to set a clear policy and strategic framework integrating medical and social welfare services in the community.
Keywords: Mental health services, mental health care system, community mental health care, Mental disorders, Japan
INTRODUCTION
As World Health Organization defines mental
health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a
contribution to his or her community”, mental
health is the foundation for effective functioning for an individual and for a community1. However,
mental illness, which affects mental health, is a leading cause of disease burden worldwide. The cost of mental health issues is estimated to be USD 6 trillion by 2030 or 25% of the global GDP2. Japan
is no exception. 19% of the Disability-Adjusted Life Years (DALYs) or “healthy” years lost in Japan was attributable to mental illness and higher than cancer and cardiovascular disease3. More than 3.92
million patients were diagnosed with mental illness in 2014 with 723,000 cases increased since 20114.
Mood disorders (158,000 increase) and Alzheimer’s
dementia (60,000 increase) were the most increased from 2011 to 2014. Depression is one of
the critical issues as it is associated with high suicide incidents in Japan which was 21,897 in 20165. However, only 30% of those who experience
symptoms of mental illness sought help due to a lack of awareness in mental health issues6. In 2008,
cost of major mental illness including schizophrenia, major depressive disorders, and anxiety disorders of ICD-10 classifications was JPY 8.2 trillion (USD 79.2 billion at annual average rate of 2008 (1USD=JPY103.46))7. This amount
The Japanese government has been promoting deinstitutionalization advocated by domestic and international communities who are concerned about human rights of patients in psychiatric hospitals9. In 2004, the Ministry of Health, Labour
and Welfare announced, “Mental Health Care and
Social Welfare Reform Vision” to promote the system transition from hospital-based to community-based10. This paper aims to provide
recommendations for achieving well-balanced mental health care in hospital and the community in Japan through the review of facilitators and barriers of current mental health care system 11.
Mental health care in Japan
This section summarizes the history of policy and legislation, and current mental health care system in Japan.
There have been three phases in the direction of mental health care legislation in Japan: private custody care, institutionalization, and community-based care. In 1900, private custody was promoted nationwide with the Law for Mentally Ill Patient Custody to deal with the severe shortage of psychiatric beds (2,000 beds for 43 million populations). Mental Hospital Law was established in 1919 advocated by a psychiatrist researcher to reduce inhumane treatment of patients including locking-up and chaining. However, private custody care continued to be mainstreamed9. After the end
of World War II, the enactment of the Mental Hygiene Law in 1950 triggered the trend towards institutionalization. The number of psychiatric beds grew from 1.4 beds per 1,000 population in 1963 to 2.5 beds in the 1970s13. Due to severe lack
of psychiatric beds (0.3 psychiatric beds per 1,000 populations), the government encouraged opening of mental hospitals by offering several governmental supports such as subsidization for hospital establishment and operations12-13,
investment scheme for private mental hospitals, and special arrangement of staff requirements applied only for mental hospitals12. Although there
was a positive movement for including social rehabilitation component to the law, one scandal of a young man with schizophrenic history attacked the U.S. ambassador in 1964 raised public opinions for prioritizing public safety through institutionalization, which resulted in the law amendment to further promote hospitalization. In 1984, a series of scandals of abusing patients in mental hospitals revealed malpractices in Japanese mental hospitals such as unnecessary involuntary admissions and a severe shortage of staff. The International League for Human Rights accused Japanese mental hospitals of violating human rights, leading to the enactment of the
Mental Health Law in 1987. This law introduced the principle of social rehabilitation, voluntary admission scheme, and monitoring system which The Mental Health Care Committee checks necessity of hospital admission and care provided in the hospitals. In 1995, taking the social welfare element into consideration, the law was amended to the Mental Health and Welfare Law.
Currently, care for patients with mental illness is provided by the two different systems: psychiatric medical system and social welfare system. Firstly, psychiatric medical system provides medical services such as inpatient and outpatient care, day/night/short care, and outreach services under the Mental Health and Welfare Law. It is strength that Japan applies Universal Health Insurance Coverage through public health insurance, and psychiatric care is free to access and available at low co-payment. On the other hand, it is weakness that priority of mental health care is low in general health care system, leading to the overburdened hospital staffs, deteriorated quality of care, and delay in deinstitutionalization13. In
2014, the total expenditure on ICD-10 mental and behavioral disorders was JPY 1.9 billion (USD 17.9 million at annual average rate of 2014 (1USD=JPY105.85)), which was 6.5 % of the total health expenditures4. Psychiatric hospitals face a
shortage of human resources, having more than 29 inpatients per a psychiatrist, 148 per a psychologist, and 41 per an occupational therapist and a social worker15. In 2004, the Mental Health
Care and Social Welfare Reform Vision was announced to promote the shift from hospital-based to community-hospital-based care10, resulting in the
gradual decrease in the number of psychiatric hospitals and beds and increase in the community services. In 2015, there were 1,064 mental hospitals with 0.3% decrease from 2014, and 336,282 psychiatric beds with 0.6% decrease14. The
average length of stay in psychiatric hospitals is also decreasing with 274.7 days in 201514. In
community, private psychiatric clinics are rapidly expanding from 400 clinics in 1985 to 3,622 clinics in 201016. On the other hand, social welfare system
METHOD
A narrative literature review was conducted to identify facilitators and barriers of implementing community mental health care for adults and the elderly in Japan, referring to Guidance on the Conduct of Narrative Synthesis in Systematic Reviews from the ESRC Methods Program17. The
objectives of this review were to identify: (i) existing models of community mental health care programs and services for adults and the elderly in Japan, and (ii) facilitators and barriers for implementing community mental health care for adults and the elderly. PsycInfo, Medline, Pubmed were searched in English, CiNii (a Japanese academic database) and Google Scholar in Japanese. The three key concepts for search terms Japan, Mental illness, and Community
mental health care were searched in the five
databases, whereas facilitators and barriers were identified from reading the contents of the selected studies. First review was conducted in the United Kingdom during August 2014, and second review in Japan from July to August 2017 to update the results of the first review.
The database search was complemented by reviewing reference lists of related papers (snowballing method) and by searching a list of government granted studies. The literature was screened first by author, title and abstract, second by duplications and availability of full-text, and third by inclusion and exclusion criteria. The inclusion criteria were: a study (i) targets adults over age 18 in Japan, (ii) published after 1965 (when the concept of community mental health care was first introduced in the law), (iii) includes mental health care intervention delivered at community level, (iv) describes a model of community mental healthcare, (v) describes/implies facilitators or barriers of implementing community mental health care. The exclusion criteria were a study targeting emergency settings or specified population (such as pre/postnatal women, children, adolescents, homeless, hikikomori, persons with mental retardation, alcohol/drug misuse, or forensic issues), so that this review can focus on adults or the elderly patients after hospital discharge. Study design was not specified in the exclusion criteria to broaden the number of search results.
RESULTS
A total of 46 papers were selected for the review after the screening process. 13 were written in English and 33 in Japanese. This review identified a variety of community mental health service
models which were summarized into six categories as below (See Table1 for a summary of the results).
Outpatient clinics
One study was identified under this category which is a retrospective study of medical and outpatient records of “memory clinic” providing detection and provision of care for persons with mild cognitive impairment and dementia. This paper implied facilitators as accessibility to the memory clinic, clear role as a comprehensive dementia care facility, a system of psychosocial care provision, and linkage with primary health care.
Outreach services
Of 16 studies identified, 7 evaluates assertive community treatment (ACT). The major facilitators for ACT implementation were highly motivated staff, collaboration among multidisciplinary professionals, leadership, sufficient funding, provision of family care, and integrated case management. The major barrier was funding shortage, caused by unclear funding source for the intersectoral services of health, welfare, and employment. Studies on home-visit nursing indicated barriers such as a lack of staff supervision and training, information-sharing among nurses, and shortage of community nursing stations, home-help and case management services.
Rehabilitation and living support
7 studies identified for this category included 4 studies of day care programs, 1 study of chronic disease management program at outpatient clinics, and 2 studies of home help services. One study on day care indicated that coordination of two different services (rehabilitation and living support) is a key facilitator. The major barriers included the deficiency in linkage among community agencies for effective service provision, a lack of structure and evaluation in day care programs, and lack of knowledge and education among home helpers in psychiatric care.
Case management and public health centers
12 studies were identified for this category, including 7 studies of case management or
and burnout, and service recognition in the community.
Community-based residential care
Among 5 studies identified for community-based residential care, 4 papers studies special nursing homes or group homes, and 1 paper on halfway houses. The increased number of residential units and staff, and home-like environments contributed
residents’ improved quality of life in nursing homes, whereas staff shortage was the major barrier in all studies. There were other barriers in relation to staff such as a lack of staff knowledge and qualification in dementia care, a lack of training/meeting/supervision, and low salaries. The study on halfway houses also points out overburdened staff as a barrier, in addition to a lack of linkage with other medical and social
welfare agencies for after care.
Work and Occupation
This category consists of 6 studies regarding Individual Placement and Support programs (IPS), workshops, vocational programs, and employment support offered by public health centers. The examples of facilitators are trial employment with shorter working hours, tailored programs to
patients’ educational levels, redeployment of existing clinical staff for vocational support, coordination with other community agencies, and collaboration among intersectoral professionals in health, welfare, and employment. The major barriers were low wage for patients, program acceptance by employers and service users, and a shortage of vocational support staff including IPS job coaches and workshop assistants.
Table1: List of the results by six categories of community mental health care models
Categories Type of care models Results
1. Outpatient clinics Memory clinic (Kawano et al. 2007)
2. Outreach services ACT (Chow et al. 2011) (Horiuchi et al. 2006) (Ito et al. 2007) (Nishio et al.2009) (Nishino et al. 2012) (Sono et al. 2008) (Setoya et al. 2009) (Sono et al. 2010) Home-visit nursing (Arai et al. 2011) (Hayashi et al. 2009)
(Kayama et al. 2009) (Kawauchi et al. 2013) (Kayama et al. 2014) (Watanabe et al. 2005) (Watanabe et al. 2009)
3. Rehabilitation and Living
support
Day care (Iwasaki et al. 2006) (Koishi et al. 2000) (Okamoto et al. 1998) (Oyama et al. 2015) Chronic disease
management programs
(Fujita et al. 2010)
Home help services (Igura et al. 2015) (Nashiro et al. 2009) 4. Case management and
public health centers Case management (Consultation support services)
(Cho et al. 2000) (Ishida et al. 2011) (Ishiwata et al. 2014)
(Kimata et al. 2009)
(Kitamura et al. 2014) (Matsumoto et al. 1998) (Onoda et al.2011)
Public health centers (Akazawa et al. 2014) (Hatashita et al. 2014-2) (Shimasawa 2016)
(Ueda et al. 2007) (Uwadaira 2008) 5. Community-based
residential care
Special Nursing homes (Nakanishi et al. 2012)
Group homes (Furumura et al. 2011) (Funamoto 2015) (Maekawa 2006)
Halfway houses (Yamazaki et al. 1980)
6.Work and Occupation IPS (Oshima et al.2014) (Unoki 2010)
Workshops (Mihara et al. 2005) (Yoshizumi et al. 1985) Vocational rehabilitation
programs
(Sakai et al. 2009)
Vocational support by Public health
centers
Most of the facilitators overlapped with the barriers because facilitator was often described as the opposite of barrier (See Table 2 for list of major facilitators and barriers extracted from the selected studies in the appendix). There are facilitators and barriers repeatedly mentioned in the six categories which are: number of staff in the community, staff knowledge and skills, staff support including supervision and educational opportunities, number of community recourses, linkage and coordination among community
resources, clear roles and leadership among local agencies and organizations, collaboration among multidisciplinary service providers, internal and external information-sharing among service providers, and funding shortage. These overlapping results were further grouped into three core themes for the analysis: funding, staff management, and collaboration among community resources. As shown in Figure 1, funding is the most important factor as since it affects feasibility of achieving the other two factors.
Figure1: Core themes of facilitators and barriers for implementing community mental health care in Japan
DISCUSSION
The final analysis identified three core themes from facilitators and barriers for implementing community mental health care in Japan: funding, staff management, and collaboration among community resources.
First, funding shortage negatively impacted provision of community mental health care services. The existing fee-for-service system reimburses less for community mental health care services especially for comprehensive community treatment such as ACT, resulting in the limited number of mental health care professionals in the community18. It is recommended that more funding
and human resources are allocated from inpatient care to community care services. The related authorities in the Ministry of Health, Labour and Welfare should consider ways of jointly financing ACT and other cross-sectoral services. In addition,
establishing an incentive scheme for mental health care professionals in the community can promote their shift from hospitals to community.
Second, staff management was the most critical issue in the selected studies. The number of service providers in the community is limited and they are overburdened. Only few staff received training for mental health care in the community settings, and opportunity of psychological support and supervision for preventing their burnout is not adequate19. Service providers in the community
requested more communication with their colleagues for case discussions, skills and information sharing, and emotional support20-23. It
Third, it was an obstacle that community resources lacked collaboration, although they are limited. One of the reasons for this is because Japanese mental health care has been separately developed around large private sectors of medical, social welfare, and employment without strong coordination and a catchment area system. On the ground, community service providers lacked a clear demarcation of the professional roles and leadership confused after a series of the policy amendments. It is recommended that local government at prefectural or municipal level shows a clear policy and strategic framework for promoting collaboration of medical and social welfare services in the community24. This
framework should (i) redefine roles of each agency, facility, and organization in the community, (ii) stipulate obligation to organize conferences for community service providers on a regular basis, (iii) specify the role of public health centers to take on leadership in organizing local community resources, and (iv) strengthen a catchment area system.
There are several limitations to this review. The review included informal databases Google scholar and CiNii to maintain sufficient number of studies for the review. Thus, the evidence level of the selected studies could be low. Due to limitation in the number of the selected studies, the results were inclined to the specific service models of outreach, case management, and services provided in public health center. The overall results might not be immediately generalized to the situation of the community mental health care service provision in Japan. Future review should include formal Japanese databases and collect comprehensive data of service models provided in the community.
CONCLUSIONS
Japanese mental health care has been traditionally hospital-based. Along with the recent policy changes, there has been a gradual shift towards community-based mental health care. This narrative literature review found that funding, staff management, and collaboration among community resources were critical for promoting Japanese community mental health care for adults and the elderly. These factors were closely entangled in the weaknesses of the existing mental health care system, such as low priority of mental health care in general health care system, resource concentration in hospitals, fragmentation of medical and social welfare sectors, and weak catchment area system. The following recommendations are made for planning
community mental health care policy and strategy at national and prefectural/municipal levels: (i) to shift funding and human resources from inpatient care to community care services, (ii) to strengthen a capacity building system and supportive environment for service providers in the community, (iii) to show a clear policy and strategic framework for integrating medical and social welfare services in the community.
ACKNOWLEDGEMENTS
The author would like to thank advisors and supervisors from the Institute of Psychiatry King’s College London and London School of Hygiene and Tropical Medicine, and researchers from Japanese research institutes who provided helpful guidance and comments for completing original version of this paper in 2014. The author is responsible for any remaining errors. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
GT is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care
South London at King’s College London NHS Foundation Trust, and the NIHR Asset Global Health Unit award. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. GT acknowledges financial support from the Department of Health via the National Institute for Health Research (NIHR) Biomedical Research Centre and Dementia Unit awarded to South London and Maudsley NHS Foundation Trust in
partnership with King’s College London and King’s
College Hospital NHS Foundation Trust. GT is supported by the European Union Seventh Framework Programme (FP7/2007-2013) Emerald project.
REFERENCES
1. Promoting mental health: concepts, emerging evidence, practice : Summary report. Geneva, World Health Organization, 2004. Available from:
http://www.who.int/mental_health/evidence /en/promoting_mhh.pdf
2. Whiteford H, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010.
3. Yamasaki M. Proposal for placement of mental disorders in Medical Plan [in Japanese][internet]. Ministry of Health, Labour and Welfare,The Japanese Association of Psychiatric Hospitals;2009 [cited 2017 July 11].
Available from:
http://www.mhlw.go.jp/stf/shingi/2r9852000 000zap2-att/2r9852000000zatm.pdf
4. Overview of national health expenditure 2014 [in Japanese] [internet]. Statistics and Information Department, Ministry of Health, Labour and Welfare; 2014 [cited 2017 July 11].
Available from:
http://www.mhlw.go.jp/toukei/saikin/hw/k-iryohi/14/
5. Statistics of suicide 2016 [in Japanese] [internet]. Statistics and Information Department, Ministry of Health, Labour and Welfare; 2017 [cited 2017 July 11]. Available from:
http://www.mhlw.go.jp/stf/seisakunitsuite/b unya/hukushi_kaigo/shougaishahukushi/jisatsu /index.html
6. Tachimori H. Study on application of results from community epidemiological study on mental health-main results from epidemiological survey on mental health: a sub-study [in Japanese]. National Institute of Mental Health, National Centre of Neurology
and Psychiatry2006.
7. Estimate of social cost of mental disorder: a project report [in Japanese] [internet]. Ministry of Health, Labour and Welfare, Keio University ;2011[cited 2017 June 14]. Available from:
http://www.mhlw.go.jp/bunya/shougaihoken/ cyousajigyou/dl/seikabutsu30-2.pdf
8. Survey on health facility and hospital report 2012 [in Japanese] [internet]. Statistics and Information Department, Ministry of Health, Labour and Welfare; 2012[cited 2017 June 14].
Available from:
http://www.mhlw.go.jp/toukei/saikin/hw/iry osd/14/
9. Fujino Y. The historical changes in the treatment of people with mental disorders in Japan: Focusing on the legal system [in Japanese]. Bulletin of Niigata Seiryo
University2005; 5:201–15.
10. Overview of mental health care and social welfare reform vision [in Japanese] [internet]. Ministry of Health, Labour and Welfare;
2004[cited 2017 June 14]. Available from: http://www.mhlw.go.jp/topics/2004/09/dl/tp 0902-1a.pdf
11. Thornicroft G, Tansella M. The balanced care model: the case for both hospital- and community-based mental healthcare. Br J
Psychiatry 2013;202(4):246–8.
12. Unoki Y. System and policy for mentally disabled people (I) from employment assistant perspective in Japan and the States [in Japanese]. The Study of Social Relations
2011;16(1):115–64.
13. Sasaki H. The role of private sector psychiatry in the Japanese mental health system in J
Ment Health 2012; 41:61–71.
14. Patient survey 2014 [in Japanese] [internet]. Statistics and Information Department, Ministry of Health, Labor, and Welfare;2015[cited 2017 June 14]. Available from:
http://www.mhlw.go.jp/toukei/saikin/hw/ka nja/14/
15. Progress of mental health services in Japan 5th ed. [in Japanese] [internet]. Department of Mental Health Policy and Evaluation, National Institute of Mental Health, National Centre of Neurology and Psychiatry; 2011[cited 2014
August 6]. Available from:
http://www.ncnp.go.jp/nimh/keikakuold/old/ archive/index.html
16. Setoya Y. Overview of the Japanese Mental Health System. Int J Ment Health
2012;41(2):3–18.
17. Popay J, Roberts H, Sowden A,et al. Guidance on the conduct of narrative synthesis in systematic reviews: a product from the ESRC Methods Programme. Swindon ESRC 2006.
18. Setoya Y. A partial study: study on differentiating functions among ACT, home-visit nursing, and day care -comparisons of service users and cross-sectional outcomes.Research project on health and welfare for persons with disabilities : A MHLW grant study on effectiveness and multidisciplinary services to promote hospital discharge and community living for persons with mental illness national institute of mental health[in Japanese].National Centre of
19. Onoda S, Nagae M. The reality of current support system for mentally Ill people living at home in their community [in Japanese].
Journal of Japanese Red Cross Toyota College
of Nursing 2011;6(1):21–30.
20. Hayashi H. Difficulties shared by visiting nurses supporting people with mental disorders [in Japanese]. Journal of Japanese Nursing
Study2009;32(2):23–34.
21. Watanabe K, Sumiyoshi K, Morimoto M, et al. Investigation about the use of mental illness patients at visiting home stations in O prefecture [in Japanese]. Bulletin of Faculty of Health Sciences Okayama University Medical
School. 2005;15:71–6.
22. Watanabe K, Oriyama S, Kunikata H, et al. Actual situations of cases in which general visiting nurses feel difficulty in taking care of psychiatric patients and the support needs of general visiting nurses [in Japanese]. Journal
of Japanese Nursing Study 2009;32(2):85–92.
23. Ueda I, Shinkai Y, Kawaharada M, et al. Factors making it difficult that public health nurses decide frequency of visit to schizophrenic patients [in Japanese]. Journal
of Comprehensive Nursing Research
2007;10(1):45–56.
APPENDIX
Table2: Summary of major facilitators and barriers by six categories of mental health care service models
Categories Facilitators Barriers
1.Outpatient clinics
➢ Strengthening accessibility, Clear role, Provision of psychosocial support, Linkage with primary care (Kawano et al, 2007) 2.Outreach
services ACT ➢ Staff motivation, Collaboration among multidisciplinary professionals, Focus on recovery, Leadership, Care plan including informal care, Case management in system, Person centered care, Family care (Ito et al, 2007)
➢ Family assessment (Sono et al. 2010) Home nursing
➢ Adequate number of home visit staffs (Kayama et al. 2009)
➢ Training opportunities for nurses (Kayama et al. 2009) (Kawauchi et al. 2013)
➢ Relationship with patients and families through providing tailored services,
Provision of comprehensive direct care and case management, Focus on family support (Kayama 2014)
ACT
➢ Lack of funding and reimbursement for ACT (Ito et al. 2007) (Nishio et al. 2009) (Setoya et al. 2009) (Chow et al. 2011)
➢ Restriction to provide treatment for mental illness (Nishio et al. 2012)
➢ Low recognition of ACT (Ito et al. 2007)
➢ Lack of collaboration with other service providers (Chow et al. 2011)
Home nursing
➢ Lack of linkage with other agencies and professionals (Watanabe et al. 2005) (Hayashi et al. 2009)
(Watanabe et al. 2009) (Arai et al. 2011) (Onoda et al. 2011)
(Kawauchi et al. 2013)
➢ Lack of staff knowledge and skills (Watanabe et al. 2005) (Watanabe et al. 2009) (Arai et al. 2011) (Onoda et al. 2011) (Kawauchi et al. 2013)
➢ Lack of psychiatric supervision for service providers (Hayashi et al. 2009) (Watanabe et al. 2009) ➢ Lack of meetings/communication
among nurses (Hayashi et al. 2009) (Watanabe et al. 2009)
➢ Lack of nursing stations and other social resources (Watanabe et al. 2005) (Onoda et al. 2011)
➢ Lack of human resources (Onoda et al. 2011)
➢ Frequent policy changes (Arai et al. 2011) (Onoda et al. 2011)
➢ High stress of nurses (Arai et al. 2011)
3.Rehabilitation and
Living support
➢ Coordinating day care and day services (Koishi et al. 2000)
➢ Improved accessibility (Fujita et al. 2010) ➢ Clear role and leadership for integrated
services, Shared goal among service providers, Staff awareness to collaborate with other resources (Oyama et al. 2015) (Igura et al. 2015)
➢ Opportunities for staff skill improvement, Support system for service providers with less experience, Network of
multidisciplinary professionals (Igura et al. 2015)
➢ Lack of linkage among public, private, medical institutions, Lack of knowledge and training
opportunities for home helpers (Nashiro et al. 2009)
➢ Difficulties to communicate with patients, Lack of support in system, lack of staff’s confidence in
providing care (Igura et al. 2015)
4.Case management Public Health Center (PHC)
➢ Clear role (Ishida et al. 2011)
➢ Linkage of PHCs and MC (Akazawa et al. 2014)
➢ PHC's leadership for organizing coordination meeting (Hatashita et al. 2014-2)
➢ Collaboration in community (Kimata et al. 2009)
➢ Public health nurses identify needs of patients at primary level, Coordination for service providers in the community such as home nurses (Shimasawa et al. 2016) ➢ Staff skill for coordinating with medical
institution for early diagnosis/treatment of dementia, Community awareness raising activities such as attending liaison committee meeting, community
involvement through events (Ishikawa et al. 2014)
➢ Lack of clear role, linkage, information sharing among local agencies (Cho et al. 2000) (Ueda et al. 2007) (Kimata et al.2009) (Kitamura et al. 2009) (Kitamura et al. 2014) (Akazawa et al. 2014) ➢ Role confusion between PHCs and
municipals (Uwadaira 2008)
➢ Lack of human resources and social resources in the community (Ishida et al. 2011)
➢ Lack of staff knowledge and skills (Ueda et al. 2007) (Kimata et al.2009) (Akazawa et al. 2014) ➢ Staff burnout at PHCs (Hatashita et
al. 2014-2)
➢ Lack of service recognition in the community (Ishida et al. 2011) ➢ Development of tailored care
services (Cho et al. 2000)
5.Community-based
residential care
➢ Communication between resident and staff, Adequate number of staff and residential units, Creating home like environment (Nakanishi et al. 2012)
➢ Staff building relationship with the
community as a mediator (Funamoto 2015)
Halfway house
➢ Lack of collaboration among social resources, Overburdened staff (Yamazaki et al. 2009)
Dementia care facilities ➢ Building dementia friendly
community environment, Lack of adequate equipment for dementia care (Maekawa 2006)
➢ Lack of human resources (Maekawa 2006) (Nakanishi et al. 2012) ➢ Lack of staff support, Lack of staff
knowledge and information of dementia care, Low staff salary (Furumura et al. 2011)
6.Work and Occupation
➢ Disclosing disabilities to employers, Shorter initial working time and trial employment (Unoki 2009)
➢ Program tailored by patients' educational level (Sakai et al. 2009)
➢ Application of "Place to train" model, Multidisciplinary professional team (Unoki 2009)
➢ Redeploying existing clinical staff (Oshima et al. 2014)
➢ Lack of opportunities for
employment and acceptance from employers, low wage (Yoshizumi et al. 1985) (Mihara et al. 2005) (Unoki 2009) (Hatashita et al. 2014-1)
➢ Lack of job coach scheme (Unoki 2009)
➢ Linkage with other workshops in the community (Mihara et al. 2005)
➢ Coordination with other resources such as local PHCs and medical institutions (Yoshizumi et al. 1985) (Hatashita et al. 2014-1)
➢ Lack of human resources and staff burden (Yoshizumi et al. 1985) (Mihara et al. 2005)
➢ Acceptance of IPS by service users (Oshima et al. 2014)
